Arm the NHS to better serve injured veterans

Those who serve in our armed forces put their lives on the line for their country. When sick or injured, the very least they should receive is high quality medical care; they have given their all and they deserve the best.

‘Problems arise when injured service personnel leave the medical care of the armed forces for the NHS’

But the best is not always provided in today’s NHS. Some veterans and former reservists, who have been discharged from the forces through injury, find the health service fails to match their own sense of duty, dedication and commitment. 

In parts of the NHS care for veterans is disjointed and inadequate, leading former personnel to feel that they have been forgotten and left to fend for themselves.

• Healthcare lessons from the battlefield: an interview with Colonel Tim Hodgetts
• Basildon and Thurrock considers clinical placements for armed forces

Care disparity

Medical care and rehabilitation in the armed forces is world class for those soldiers injured in action in the war in Afghanistan. This care is second to none. In a recent study, which looked at outcomes for 52 British combat amputees from Afghanistan and Iraq, only eight were discharged, with the other 44 continuing to serve. Even more impressive, 33 returned to active service.

But problems arise when injured or disabled service personnel have to leave the medical care of the armed forces and are compelled to rely on the NHS. 

‘The NHS is undermined by bureaucratic structures, inefficient working practices and poor coordination’

The armed forces covenant holds that special consideration should be given by our society to veterans in recognition of the sacrifices they have made on our behalf. Although the Department of Health has done much for mental health, this fine sentiment is not always translated into reality. Often, the quality and access to care can be a lottery.

The NHS is facing unprecedented challenges. Financial austerity, a rapidly expanding and ageing population, as well as significant advances in medical technology, make it increasingly difficult to provide universal free care for the population.

The finances of the NHS remain under extreme pressure, with experts predicting a shortfall in funding of no less than £30bn by the end of the decade. Some believe that ever more money is needed to save the NHS. I believe that we as a profession need to step up to the plate to help solve this problem. 

Bureaucratic block

Financial constraints are not solely to blame for problems in the NHS. It is still undermined by operational failings such as overwhelming bureaucratic structures, inefficient working practices and poor coordination between departments.

At the government’s and NHS England’s request, I am currently undertaking a national review of orthopaedic practice in England through the Getting it Right First Time pilot. I have visited more than 170 hospitals so far, giving me a unique insight into elective orthopaedics in the NHS.

‘By getting care right in our hospitals, commissioners will be confident that the services they buy are high quality’

The final report is due later this month, and action on my findings would fundamentally change the way we deliver orthopaedic services, increase the quality of care, reduce complication rates and reduce variation of practice.

By getting the provision of care right in our hospitals, which account for 80 per cent of the cost, commissioners could be confident that the services they buy are of the highest quality and best value.

This would result in massive savings for the NHS – I predict up to £2bn in orthopaedics over five years – without compromising care. This is an example of how senior clinical leadership, working with the British Orthopaedic Association, can provide solutions we are desperately seeking.

The current problems in the NHS have an impact on the care of veterans, which is all the more regrettable given the nation’s moral obligations to these men and women.

Prioritising injuries

I have recently published The Chavasse Report, named after an inspiring and heroic doctor in the Royal Army Medical Corps, Captain Noel Chavasse. He is one of only three men to have been awarded the Victoria Cross twice. The report highlights the problems, but importantly, also provides the solutions to improve musculoskeletal care for our reservists and veterans. The Defence Medical Services assisted me throughout.

‘One recent study found that half of GPs did not know that veterans were meant to be prioritised’

Through my work as a senior orthopaedic surgeon, I have seen that NHS services for veterans need to be improved and better coordinated such as with musculoskeletal injuries, which account for more than 50 per cent of discharges from the forces, compared to around 15 per cent for mental health problems.

One young Royal Marine veteran, David Martyn, is a case in point. He was shot in the knee in the Afghanistan campaign and received excellent treatment at Camp Bastion and Queen Elizabeth Hospital in Birmingham. But when he came under the care of the NHS he was told there was little that could be done except amputate the leg if the pain worsened.

Eventually he was referred to the Royal National Orthopaedic Hospital Trust in Stanmore, where we were able to significantly improve his quality of life. He should have been referred, and much earlier.

This is not an isolated event. In 2007, in response to complaints from the Royal British Legion about veterans’ needs being ignored, the then health secretary Alan Johnson ordered that they should receive priority treatment and bypass waiting lists. That instruction has only had a limited success.

One recent study found that half of GPs did not know that veterans were meant to be prioritised, while a survey by the RBL discovered that only 22 per cent of veterans have been offered fast track care. 

Fast tracking treatment

We have a moral duty to significantly transform the healthcare of veterans. The Chavasse Report provides the solutions that will work, make fast track treatment a reality and, just as importantly, improve the coordination of care.

‘Units would link up with rehabilitation units within the military and the personnel recovery centres’

We need to provide a seamless transition of care pathway from the armed forces to the NHS. We also need to create a network of 30-40 NHS service hospitals, identified and chosen on the grounds of excellence in orthopaedics.

These are NHS hospitals that treat patients to a very high standard and have already been identified through the hospital visits I have undertaken. They would continue to treat their own population as well as veterans.

In addition, we should create about 14 dedicated NHS veteran rehabilitation units for use by veterans, inspired by the care seen within the armed forces. These would also provide psychological support and chronic pain management.

The units would link up with the rehabilitation units within the military and the personnel recovery centres funded by Help for Heroes and the RBL. This would ensure a seamless transition of care and joint learning opportunities between the NHS and the armed forces. 

The services of these rehabilitation units should also be available to normal NHS patients, leading to a reduction in medical complications and improved recovery and rehabilitation. This would benefit our workforce, improve care for all who access the NHS and have positive consequences for the economy.

Beacons of excellence

There is an opportunity for NHS service hospitals and NHS rehabilitation units to act as beacons of excellence, both to the rest of the service and to the wider world, by delivering the highest standards of care to veterans and NHS patients.

‘Setting up networks within the NHS is not a new phenomenon and it can be very successful’

There will be questions about costs, but I believe that the rehabilitation units would cost £14m-£20m to set up, could be funded by the government using the LIBOR fines, or from the massive savings from the Get it Right First Time national pilot.

If we get the provision of care right, then commissioners and NHS England, which is already working hard on this issue, would be able to commission in confidence, knowing that they are commissioning high quality care and getting best value for each pound spent.

Setting up networks within the NHS is not a new phenomenon and it can be very successful. The result of setting up the major trauma networks is a massive improvement in outcomes for patients with major trauma. If commissioning alone had been the driver, then it is unlikely that this model would have evolved

The Chavasse Report has the support of the Defence Medical Services, politicians, charities, leading figures in the armed forces and the Duke of York. 

On armed forces day in June there were many heartfelt words spoken about the debt we owe to our veterans. Now is the time for action and for us to honour our debt and finally resolve this issue.

If it doesn’t happen this year, with the focus on the 100th anniversary of the outbreak of the First World War, as well as the 70th anniversary of D-day, it never will.

Professor Tim Briggs is president of the British Orthopaedic Association, chair of the Federation of Specialist Hospitals and a consultant orthopaedic surgeon